The home as an appropriate setting for women undertaking cervical ripening before the induction of labour.
ABSTRACT to explore women's experiences of cervical ripening using isosorbide mononitrate (IMN) in the home as part of the main randomised controlled trial.
qualitative study with semi-structured interviews carried out at three weeks post partum. Interview transcripts were analysed to identify recurrent themes, focusing on why women became involved in the study, their views about both the self-medication and the home setting, and whether they would repeat the experience.
twenty women enrolled in the main randomised controlled trial.
the study is part of a double-blind randomised controlled trial with 350 patients investigating whether a nitric oxide donor (IMN) used in cervical ripening improves the process of induction of labour.
women liked the opportunity to remain at home during the cervical ripening process. Timing and setting were central issues; women hoped that it would hasten labour, while the home was seen as a setting offering freedom, security and reassurance, as opposed to the hospital, seen as constraining. Two women reported problems with IMN but the remainder reported that they would repeat the experience.
women were very positive about the opportunity to undertake cervical ripening at home. It is important to explore this setting further for appropriate interventions.
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ABSTRACT: Objective To compare clinical outcomes from outpatient with inpatient cervical prostaglandin E2 ripening for low risk labour induction.DesignRandomised controlled trial.SettingTwo tertiary hospitals in Adelaide, Australia.PopulationWomen with uncomplicated term pregnancies, scheduled for induction of labour for reasons of post-dates or for social reasons.Methods Eight hundred and twenty-seven women were randomised at induction decision to an outpatient or inpatient group. All women had CTG monitoring before and after vaginal PgE2 administration. The inpatient women were admitted and the outpatient group was discharged home overnight with instructions to return if labour established or rupture of membranes occurred. Next morning, outpatient women were admitted for rupture of membranes or further ripening. After membrane rupture, both groups received routine care.Main outcome measuresOxytocin use, maternal and fetal outcomes, and whether planned outpatient management was achievable.ResultsThere were no significant differences in oxytocin use (2.5% difference, CI−4.3 to 9.4), caesarean sections (−0.59% difference, CI−6.3 to 5.1), epidural use (1.5% difference, CI−5.1 to 8.2), vaginal delivery within 24 hours (−8.2% difference, CI−17.6 to 1.3) or labour complications. More than half of the randomised women did not receive the intervention as they laboured spontaneously, or did not require ripening. The post-hoc analysis of women who received ripening also indicated no statistically significant differences in the patterns or results, with the exception of outpatient women having a longer mean length of active labour (mean difference 66 minutes, CI 4–128 minutes). Outpatient women who received ripening were diagnosed more frequently with non-reassuring CTG monitoring and hyperstimulation, with less than half of the women going home and remaining home overnight.Conclusions This study demonstrated no clinical advantage or disadvantage in prostaglandin E2 outpatient cervical ripening. Uterine stimulation following prostaglandins may preclude a woman from going home or remaining at home overnight and may not be the best agent for outpatient ripening.BJOG An International Journal of Obstetrics & Gynaecology 05/2014; · 3.76 Impact Factor
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ABSTRACT: Objective To compare the costs of inpatient (usual care) with outpatient (intervention) care for cervical priming for induction of labour in women with healthy, low-risk pregnancies who are being induced for prolonged pregnancies or for social reasons. Methods Data from a randomised controlled trial at two hospitals in South Australia were matched with hospital financial data. A cost analysis comparing women randomised to inpatient care with those randomised to outpatient care was performed, with an additional analysis focusing on those who received the intervention. Results Overall, 48% of women randomised into the trial did not receive the intervention. Women randomised to outpatient care had an overall cost saving of $319 per woman (95% CI -$104 to $742) as compared with women randomised to usual care. When restricted to women who actually received the intervention, in-hospital cost savings of $433 (95% CI -$282 to $1148) were demonstrated in the outpatient group. However, these savings were partially offset by the cost of an outpatient priming clinic, reducing the overall cost savings to $156 per woman. Conclusions Overall cost savings were not statistically significant in women who were randomised to or received the intervention. However, the trend in cost savings favoured outpatient priming. What is known about the topic? Induction of labour is a common obstetric intervention. For women with low-risk, prolonged pregnancies who require cervical priming there has been increased interest in whether this period of waiting for the cervix to 'ripen' can be achieved at home. Outpatient priming has been reported to reduce hospital costs and improve maternal satisfaction. However, few studies have actually examined the cost of outpatient priming for induction of labour. What does this paper add? This is the first paper in Australia to both assess the full cost of outpatient cervical priming and to compare it with usual (inpatient) care. This is the first costing paper from a randomised controlled trial directly comparing inpatient and outpatient priming with prostaglandin E2. What are the implications for practitioners? For women with prolonged, low-risk pregnancies, a program of outpatient cervical priming can potentially reduce in-hospital costs and free up labour ward beds by avoiding an additional overnight hospitalisation.Australian health review: a publication of the Australian Hospital Association 09/2013; 37(4):467-73. · 0.70 Impact Factor
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ABSTRACT: To evaluate whether home cervical ripening is safe and results in shorter hospital stay.Obstetrics and gynecology. 07/2014;
Glasgow Caledonian University
Research Online @ GCU
School of Health
The home as an appropriate setting for women
undertaking cervical ripening before the induction
Glasgow Caledonian University, firstname.lastname@example.org
Jane E. Norman
Shrikant S. Bollapragada
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Digital Commons Citation
Reid, Margaret; Lorimer, Karen; Norman, Jane E.; Bollapragada, Shrikant S.; and Norrie, John, "The home as an appropriate setting
for women undertaking cervical ripening before the induction of labour" (2011).School of Health.Paper 89.
The home as an appropriate setting for women undertaking cervical ripening
before the induction of labour
Margaret Reid, PhD (Professor of Women’s Health)a,n, Karen Lorimer, PhD (Researcher)b,
Jane E. Norman, MD, FRCOG (Professor of Maternal and Fetal Health)c,
Shrikant S. Bollapragada, MRCOG (Consultant in Obestrics and Gynaecology)d,
John Norrie, MSc (Professor of Clinical Trials and Biostatistics)e
aPublic Health and Health Policy, Division of Community Based Sciences, University of Glasgow, Glasgow, UK
bMRC Social and Public Health Sciences Unit, University of Glasgow, Glasgow, UK
cCentre for Reproductive Biology, The Queens Medical Research Institute, University of Edinburgh, Edinburgh, UK
dMaternal and Reproductive Medicine, Division of Developmental Medicine, University of Glasgow, Glasgow Royal Infirmary, Glasgow, UK
eRobertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
a r t i c l e i n f o
Received 29 March 2009
Received in revised form
7 October 2009
Accepted 8 November 2009
a b s t r a c t
Objectives: to explore women’s experiences of cervical ripening using isosorbide mononitrate (IMN) in
the home as part of the main randomised controlled trial.
Design: qualitative study with semi-structured interviews carried out at three weeks post partum.
Interview transcripts were analysed to identify recurrent themes, focusing on why women became
involved in the study, their views about both the self-medication and the home setting, and whether
they would repeat the experience.
Setting: the home.
Participants: twenty women enrolled in the main randomised controlled trial.
Intervention: the study is part of a double-blind randomised controlled trial with 350 patients
investigating whether a nitric oxide donor (IMN) used in cervical ripening improves the process of
induction of labour.
Findings: women liked the opportunity to remain at home during the cervical ripening process. Timing
and setting were central issues; women hoped that it would hasten labour, while the home was seen as a
setting offering freedom, security and reassurance, as opposed to the hospital, seen as constraining. Two
women reported problems with IMN but the remainder reported that they would repeat the experience.
Implications for practice: women were very positive about the opportunity to undertake cervical ripening
at home. It is important to explore this setting further for appropriate interventions.
& 2009 Elsevier Ltd. All rights reserved.
In Western countries, induction rates over the last decade have
remained stable within the UK, with around one-fifth of all women
having their birth induced (Clinical Effectiveness Support Unit,
2001). Although there has been steady progress in research on the
drug therapies associated with induction, research on women’s
experiences of induction has been less well developed. Unusually,
in this randomised controlled trial (RCT) of which the substudy
reported forms a part, women undertook cervical ripening in the
home setting. The aim of the substudy was to explore women’s
experiences of taking the drug in this novel setting.
Induction is routinely carried out using various agents to ripen
the cervix. Although prostaglandins are widely used, they can
cause adverse effects for mother and fetus (Wong et al., 1998;
Clinical Effectiveness Support Unit, 2001). More recently, nitric
oxide (NO) donors such as isosorbide mononitrate (IMN) have
been employed as they have been shown to stimulate the uterus
without causing adverse effects of clinical importance during the
ripening process (Osman et al., 2006). Studies have reported on
NO donors in a range of settings, including induction of women as
inpatients (Osman et al., 2006) and outpatients (Neale et al., 2002;
Bullarbo et al., 2007). Research has, however, focused upon the
clinical efficacy of IMN with only brief reporting of women’s
preferences and satisfaction with the drug (e.g. Osman et al.,
2006; Bullarbo et al., 2007).
Although recent national reviews of childbirth have included
women’s experiences of induction within their remit (Redshaw
et al., 2007; Healthcare Commission, 2008), the lack of women’s
Contents lists available at ScienceDirect
journal homepage: www.elsevier.com/midw
0266-6138/$-see front matter & 2009 Elsevier Ltd. All rights reserved.
E-mail address: firstname.lastname@example.org (M.R. Reid).
Midwifery 27 (2011) 30–35
voice in research on the topic of induction has been noted
(Westfall and Benoit, 2004; Alehagan et al., 2006). Furthermore,
studies accessing women’s views directly through interviews or
other qualitative methods remain the exception (Blix-Lindstr¨ om
et al., 2004; Westfall and Benoit, 2004; Kornelsen, 2005). There is,
however, a small but important literature on the topic of women’s
experiences of induction, including women’s satisfaction with
induction of labour. All are concerned with women’s experiences
of labour and induction in hospital, and thus they relate to the
structured medical setting in which decision-making and choice
take place. While studies focus upon different aspects of the
process, recurrent themes emerge including fear of pain (Nystedt
et al., 2006; Nuutila et al., 1999), the importance of being involved
with decision-making (Nuutila et al., 1999; Blix-Lindstr¨ om et al.,
2004) and the significance of feeling in control of the situation
(and fear of not being so) (Nystedt et al., 2006; Green and
Baston, 2003). Shetty et al. carried out a comparative survey of
satisfaction of a group of women undergoing induction with those
who went into labour spontaneously (Shetty et al., 2005); the
research demonstrated that the speed of induction was an
important (negative) feature, while overall, those who laboured
spontaneously were more satisfied.
As the focus of the substudy was the home rather than the
hospital, research within the home also has relevance to this
substudy. The language and meaning that women attach to
remaining at home during labour is demonstrated in several
studies (mostly Scandinavian) of women who have chosen a home
birth. They demonstrate that these women share some values
with those who have hospitalised births, such as the opportunity
for control during labour (Viisainen, 2001), but most relevant to
this substudy, they value the importance of the familiarity of the
home (Sj¨ oblom et al., 2006) which provides a feeling of support
and calmness (Johnson et al., 2007). In a 1989 study, Hodnett
focused upon ‘setting’ in a comparative Canadian survey of 160
women, 80 of whom were planning a home birth and 80 a hospital
birth (Hodnett, 1989). Among the differences reported, home birth
women spent less time in bed than hospital subjects, and were
more able to experience freedom of movement and self-expres-
sion including walking, showering, and eating and drinking when
they wished. Hospital subjects were rarely allowed food or fluids,
and overall had their environment more tightly controlled.
The substudy of women’s views reported below was estab-
lished to ascertain how women managed the treatment in the
home, providing in-depth evidence about a little known topic.
Qualitative methods provide the opportunity to explore the ways
in which individuals make sense of new situations and the
meanings that they may assign to their experiences (Denzin and
Lincoln, 1994). Thus the approach chosen was to interview a small
number of women from the larger set of the study respondents.
The paper addresses the pre-induction stage at home rather than
the subsequent hospitalisation and birth, and will discuss three
topics, namely why women became involved in the study, their
views about both the self-medication and the home setting, and
whether they would repeat the experience.
The RCT set out to test the hypothesis whether IMN (40 g)
vaginally taken every 16 hours with up to three doses improves
the process of induction of labour compared with placebo, focusing
upon clinical, economic and women’s satisfaction outcomes [(for a
detailed description of the RCT, see Bollapragada et al. (2009)]. The
design was a double-blinded RCT carried out between March 2005
and December 2006, with a sample of 350 women attending the
Princess Royal Maternity Hospital, Glasgow, for whom cervical
ripening and labour induction had been planned. Women were
required to have all of the following characteristics: nulliparity,
singleton fetus, cephalic presentation, 437 completed weeks of
gestation, modified Bishop score o7, and willingness to self-
administer vaginal tablets. Excluded patients were o16 years of
age, those who needed to deliver within the next 48 hours for
maternal or fetal reasons, or those with ruptured membranes.
Once the clinical decision to induce their labour was made,
study women were asked for written informed consent to
participate and were subsequently randomised by the clinical
researcher up to seven days prior to scheduled admission for
induction of labour. They were given randomised study medica-
tion (either IMN tablets or placebo) with instructions to self-
administer the tablets vaginally at 48, 32 and 16 hours prior to
induction (Bollapragada et al., 2009).
In order to explore women’s views of taking IMN, two
approaches were taken. The first was a series of one-page self-
administered questionnaires (Bollapragada et al., 2009). This
paper reports on the second approach which formed a discrete
substudy: retrospective, one-to-one, in-depth interviews were
carried out with a small group of women who had participated in
the main trial. Neither the clinicians nor the social scientists
(MER, KL) had prior expectations about how the women would
respond to the request to undergo pre-induction in the home
setting, and the lack of literature on the topic offered little
indication as to how acceptable women would find the medica-
tion and/or the setting.
Recruiting the sample
At the start of the trial, the women had the drug explained to
them (by the clinical researcher), the procedure (i.e. self-
administration of the drug three times in the home setting) and
any possible side-effects such as headache. A convenience sample
of women was established, and within 24 hours of birth, details of
45 women from the trial who were willing to participate in the
substudy were passed consecutively to the social scientist
researcher (KL), who made first contact with the women in
hospital. At this time, women were provided with a description of
the substudy. KL explained that she was not medically trained and
that the substudy was set up to explore their experiences and
views of the procedure and the home setting. It was agreed that
they would be contacted in two weeks to arrange a suitable time
and date to be interviewed. No one declined further contact.
All women were telephoned. One number was found to be
unobtainable, while no contact could be made with a further nine
women, the telephone ringing out each time, or a message left on
an answering machine but with no subsequent response. Three
women who were contacted refused to take their involvement
further (too tired, baby had colic), while another four women were
out when the researcher visited at the arranged time. Subsequent
telephone contact did not improve recruitment with these women.
A total of 22 women participated in an interview in the home
setting. Of these, the first was treated as a formal pilot and was
subsequently excluded. One other woman went into spontaneous
labour prior to starting the treatment and was quickly admitted to
hospital; her interview, although carried out, was excluded from
the final analysis. Thus, a total of 20 interviews were included
in the analysis. The six remaining women were not followed-up as
data saturation was reached at interview 17, with the further
three interviews serving to confirm this.
Prior to recruitment, 10 informal pilot interviews took place in
hospital in order to refine the interview schedule. This resulted in
an expansion of the section on women’s expectations about the
drug, and more time spent probing women’s views of staying at
M.R. Reid et al. / Midwifery 27 (2011) 30–35
home. The final interview schedule consisted of three main parts:
women’s expectations of the pre-induction process (including the
reasons for their participation in the trial); their experiences of
taking the drug in their home; and the relative importance of the
home environment and whether or not they would repeat the
All interviews were audio-recorded and transcribed verbatim
and coded using Atlas.ti (Scientific Software Development, Berlin).
Interview transcripts were read repeatedly and coded to identify
emerging themes, within which the key areas of the schedule
became the organising themes of the analysis (Creswell, 1998).
Emergent themes were identified, such as the importance
that women attached to the home and its parameters, and the
significance of the home developed into a major part of the
analysis. Recurring themes were checked independently by MER
until the final set was agreed. Whilst care was taken to ensure
that any ‘contradictory’ cases were identified, in reality, the
women’s views largely fell into broadly similar categories,
although deviant cases are reported below.
It is important to note that during the interviews, the trial was
still on-going and the code had not yet been broken, thus neither
the women nor the interviewer knew to which arm of the trial the
women belonged. This information became known after the first
layer of analysis was complete, when it was found that exactly
half of the 20 interviewees had received IMN. A retrospective
analysis was subsequently undertaken to explore potential
differences between the two trial groups. Little difference was
evident. The similarity was not surprising; the study design was a
double-blind trial, so neither the women nor the staff knew who
had received the medication. The function of the IMN was to
soften the cervix prior to induction, and the women themselves
were not aware of the softening process. Apart from headache
(reported below), the overwhelming experience of being at home,
of administering the medication and of waiting for the inevitable
move to hospital was the same for both groups of women.
Ethical approval was granted by the North Glasgow University
NHS Ethics Committee.
The mean age of the 20 interviewees was 29.2 years (range 19–
32 years), with little difference between those in the trial arm and
those in the placebo arm (29.6 years and 28.7 years, respectively).
This was slightly higher than the trial population (mean age 27.2
years). Those who were not interviewed were notably younger,
with a mean age of 22.6 years (range 16–36 years). The sample
was analysed for level of social deprivation by residence postcode
using the Scottish Index of Multiple Deprivation (SIMD), the
measure of relative deprivation now used in Scotland (Scottish
Executive, 2006). The interviewees did not differ according to
SIMD rank, with six of 10 women in both trial groups living in data
zones which fell into the lowest two ranks of deprivation. Of the
non-responders, 11 of 151came from the two most deprived ranks.
Women’s understanding of the drug
During recruitment, all women were given the same written
and oral information on the study drug. When interviewed, a few
women had remembered quite precisely that IMN was a cervical
ripening drug (‘to try to get your cervix open before you actually go
into hospital’, Interviewee 10, age 33). Some also understood that
while they were in the trial, they may not have been allocated
to the IMN group, but might be given a placebo. All had been
told that the drug could give them a headache and were asked
about symptoms. Of those in the IMN group, nine reported
headaches but most said that it diminished quickly or they took
a painkiller and it went away. One woman stopped taking the
drug after the first dose because of considerable side-effects of
headache, nausea and hot flushing, whereas one reported no
symptoms. None of the women in the placebo group reported a
headache. Women tried to guess which trial group they were in,
but while none of the 10 interviewees from the placebo group
reported a headache, some in the placebo group in the main sample
did, thus headache was not a guarantee of which group one was in:
I guess you always hope that it will start something and being
part of the study you think ‘I’ve got the headaches I’m getting
hot flushes, I’m feeling nauseous, this is it, I’ve got the real pill
here’ (Interviewee 11, age 31).
I thought, I was just hoping that it would bring it [labour] on,
you know, every wee twinge I got, I was like, oh, that is, is that
it, you know but, just basically hoping it would work, but it
never and I used the three of them and, obviously I got the dud
ones [laughs], the blankety-blank ones (Interviewee 9, age 36).
Women were asked about administering the drug; a small
tablet to be inserted vaginally at the three time periods. Few of
the 20 respondents reported problems with the insertion. All
reported managing the timing, although this required them to
stay up late (11 pm) and wake up early (for the 7 am tablet). They
were practical in the management of the drug, with a minority
asking their husband to insert the tablet if they had experienced
difficulties, and setting an alarm so that they would remember to
take the drug at the appropriate time; mobile phone alarms were
commonly reported. For example, Interviewee 11 (age 31) felt
that it was straightforward:
It was very easy. I don’t know how I’d have managed without a
partner to insert the tablets, I don’t think I could have got my hand
over my bump to do it and I think that would have to be taken
into consideration if maybe it was a single parent or somebody
who was going to be on their own, that’s the only thing.
Motivation to participate in the trial
The trial had a high participation rate and it was felt important
to understand why women were willing to take part. Interviews
explored this in some depth, with the three most common
reasons cited being confidence in the safety of the medication for
both the baby and themselves, the issue of time at home, and
setting, wishing to stay at home for as long as possible. Some
women reported initial caution about taking the medication and
asked a number of questions about the safety of the drug and its
side-effects. That it was a drug which had already been used both
as a cervical ripening drug and heart disease was seen as
reassuring, although many discussed the decision with someone
else, often their partner or their mother, and only agreed to take
part with the support of the other person:
At first, like when I first heard of the benefits and everything
of it I thought, that sounds really good and then like when
the study, when the research thing kinda came into my mind
(the study was carried out at a time when there were widely
reported serious side-effects with a large national RCT)
I thought, I’ll have a wee think about it and then phone back
(Interviewee 17, age 27).
1Two missing data.
M.R. Reid et al. / Midwifery 27 (2011) 30–35
Two further reasons influencing their decision to take part
were concerned with time and place. Women had already taken
pro-active measures to trigger labour on their own, such as
drinking raspberry tea, eating pineapple and curries. The drug was
seen as a therapeutic way of starting labour, and many agreed
with the respondent who said ‘ I was so big, I was uncomfortable.
I think we both just thought, anything’ (to help start labour)
(Interviewee 9, age 36).
Many women were willing to become involved with the study
because it provided them with the opportunity to stay at home for
longer and, by the same token, out of hospital during the cervical
ripening phase of labour induction. Women attached considerable
value to being in the home environment:
I: Why was, why did you decide to take part?
R: Just so I wouldn’t, hopefully, I would get the, the active
pessary and I wouldn’t be in hospital for as long (Interviewee
14, age 26).
‘yCause it is a thought going to hospital and you think if you
can cut down your stay, all the better (Interviewee 12, age 30).
Women anticipated the hospital environment as being less
friendly, flexible and comfortable; all features which they posi-
tively attributed to the home environment. After the medication
had been taken, the majority of women reported returning to their
daily routine. Although two (IMN) women who had experienced
nausea and headaches said that they had not been very active,
many of the others in both trial groups reported that they defined
the situation as normal (e.g., ‘I just got on with my normal’) and did
not see the taking of the medication as a reason to upset their
established routines in late pregnancy. Their home activities
included staying at home, preparing for the birth. Many reported
being active, rather than sitting down and resting: I was just dain
(doing) housework and tidying my room and fixing all the wean’s
(baby’s) stuff oot aw the time as well (Interviewee 8, age 20).
Although technically being ‘at home’ during this period, many
left the house to go shopping, for a walk, visiting friends or out to
eat. Interviewee 11 gives an illustration of the types of activity
that was common: I got dressed, I went up to (place), went to visit
my mum and dady went to see my nieces and nephew, just a
normal weekend for me, I didn’t change anything (Interviewee 11,
age 31). By contrast, a small group talked of taking life quietly and
trying to get some rest:
I was just tired and sleeping all the time (Interviewee 18, age 22).
I was in my bed ‘cause I was trying to get a sleep because I’d
been up, this was half one, and I’d had maybe an hour’s sleep
or something and I was getting contractionsy so I was in my
bed trying to get some shut eye (Interviewee 3, age 30).
Women were asked whether they would have preferred to have
gone into hospital for their pre-induction. All said no. Why women
liked staying at home at this time in their pregnancy was explored
in some depth. Reasons offered were based around two related
views, the first being that they felt more relaxed at home, and the
second being that they felt anxious about being in hospital.
Associated with these positions were packages of related views.
Women used a consistent series of adjectives to describe how
they felt at home, reporting that they felt ‘relaxed’ in a ‘familiar’
setting and that there was a sense of ‘freedom’ of movement. The
familiarity of the environment was seen as important, along with
the possibility of being able to do what they wanted, when they
wanted. Thus issues of being in control and the enjoyment
of being in a private space were strongly stated. Interviewee 3
(age 30) noted ‘I would rather have been at home than anywhere
else ‘cause I was in my own bed and I had my own kinda home
comforts, and I could eat as well’, whereas Interviewee 18 (age 22)
similarly emphasised the importance of the familiar: I was more
relaxed when I was in the house andy it was just more
comfortable being at home. You’re just in your own house rather
than being in the hospital. It’s better being in the housey.
Additionally, home was associated with having the support of
their partner and/or family. Partners (and sometimes mothers)
were brought into the discussion frequently as participators in the
process. They had been part of the decision-making about
involvement in the study and were there to allay anxieties about
the impending birth. As Interviewee 8 (age 20) said: No, I think it
would be better at home because I think you can talk to the
family, as I said, and if you’ve got any problems then you can say
to your family as well, but if you’re in the hospital, you know, it’s
just no’ a nice place to be.
Interviewee 11 (age 31) was typical when she contrasted the
home environment with her hospital experience, noting, as did
others, that her perception was of hospital being an institution for
sick, not healthy, people: It’s much more relaxed being at home
than it is being in the hospital environment where you, no matter
what they say you’re not ill but you end up feeling ill because
you’re in that environment, it’s much better to have it at home,
you can sit and relax, feet up, visitors whenever you want.
A minority of the sample did report anxiety about staying at
home, however. A few had minor concerns about being at home
while they administered the treatment, notably whether they
were administering it correctly, and whether it might trigger a
quick labour. Thus some reported feeling a little anxious at home,
specifically around administering the first tablet. ‘I was a wee bit
nervous’ noted Interviewee 2 (age 21), whereas another said
‘I was nervous after I put the first oney but wi (with) the second
two I was all right’ (Interviewee 8, age 20). When asked whether
she had any anxiety about taking the medication, Interviewee 14
(age 26) admitted that she dealt with her concerns: Just a tiny tiny
wee bit at the back of your mind, you’re thinkingy something’s
going to go wrong, but other than that, absolutely fine.
Others were concerned that once the tablet was inserted, they
might go straight into labour; a misunderstanding about the drug
as this was not what they had been told at recruitment:
I was fine about it. I guess the one concern before I had it was
that it would happen right away and I wouldn’t get time to get
to hospital. You don’t know what to expect. You imagine,
you’re insert this tablet and you’re going to go into labour and
you won’t manage to get to hospital but apart from that, no I
felt fine (Interviewee 12, age 30).
Many of the broader concerns reported by these women facing
childbirth for the first time were about going into labour, and
were associated with both the biological and social events which
lay on the horizon.
Views about hospital
By the time they were interviewed, all respondents had
experienced a hospital stay, which might have influenced the
often stark contrast made between the home and hospital. Many
saw hospital as a place associated with illness and discomfort, the
opposite of what they wished and what they felt was offered by
staying at home. Thus the lack of constraint of the home
environment in terms of autonomy, familiarity and comfort of
the surroundings, as well as the level of support of family and
friends, was repeatedly contrasted with the limitations, both
physical and emotional, of the hospital environment:
(In hospital)..you can’t do what you want to do. You can’t eat
your own food, you can’t sleep at night because it’s noisy and
M.R. Reid et al. / Midwifery 27 (2011) 30–35
people are being in and out, you can’t go to the gym. Em, you
can’t phone your friends, whatever, you can’t just. Hospitals
are places for sick people, really, not a place for people that are
taking a tablet once every 16 hours (Interviewee 13,
Women repeatedly reported that they saw hospital as a place
for sick people, and that they did not feel ill, nor did they see being
pregnant as an illness. The logic was that although they were
willing to enter hospital to give birth, they felt that it was also
reasonable to stay at home for as long as possible prior to the
birth. The opposing concepts of illness and health in the two
settings were all important.
Whether or not women would repeat the experience was a
crucial question. The majority of women were very positive about
the experience, saying that they would undergo cervical ripening
at home again. The interviews suggest that the setting predomi-
nated in their recall. Interestingly, although women were not
asked explicitly about home birth, a number spontaneously
separated out the experience of being at home pre-induction,
which they felt was positive, and having a home birth, noting that
they would not wish the latter:
I certainly don’t want to be in hospital, you know, the food’s
crap, you know, and I would certainly much rather be at home.
I wouldn’t go for a home birth or anything like that. I mean,
you’ve still feel a lot more secure in hospital (for the birth) and,
obviously, staff are there to help you (Interviewee 9, age 36).
Only three out of 20 women said that they were uncertain
about repeating the experience or they would not do the same
again. Two (IMN group) felt that their headaches were sufficiently
bad to leave them wishing not to repeat the experience, although
it was the headache and not the setting which they felt had put
them off the experience. One other woman (placebo arm) guessed
that she was in the placebo group and said that she was
disappointed; nevertheless, she said if she could be guaranteed
the IMN, she would do it again because her main concern was
speeding up the induction process and thus reducing the time
spent in hospital. The other respondents viewed the experience
positively, even though some had a long wait in hospital and
reported that they preferred spending their pre-labour at home.
Additionally, some felt that taking IMN had given them an easier
labour. Interviewee 7 (age 33) summarised her view: I would
encourage it and like, if the doctor asked me if I would
recommend it to people I would but, again, it’s no for everybody.
Some people would prefer, they might be frightened or they
might no like getting it done in the house but I would recommend
it. My personal view is that I would rather be here (at home).
Induction rates in the UK (and indeed in much of the Western
world) remain around one-fifth of all women undergoing child-
birth. Induction, therefore, is a common experience. It is
important to explore ways in which the procedure may be
managed as acceptably to women as possible. This substudy is
unusual in its focus on women’s views of the pre-induction
process and in the home.
Losing over a third of the sample in this kind of study was
predictable; early postpartum women have many demands on
their time and energies, and the prospect on an interview when
one has had broken sleep and fractious baby is not always
appealing. Previous research of women early post partum had
resulted in postnatal responses to surveys being somewhat but
not substantially higher (Shields et al., 1998, Shetty et al., 2005).
The non-responders as well as the responders were similar to
those in previous studies from the same hospital (cf. Turnbull
et al., 1996), with the majority of the women being categorised as
very deprived, whatever measure used. Although numbers are
very small, the non-responders were younger than the women
who finally participated in an interview and this factor should be
taken into consideration with the findings.
Women reported few problems in the self-administration of
the IMN, although some said that it was easier for someone else
(their partner) to administer the tablet vaginally. For most
women, the side-effects of IMN were confined to a headache,
which they felt was manageable and dealt with through
medication and sleep. For a small group of women, the headache
was strong and uncomfortable and marred the experience.
Formostof the sample,
involved with the study resulted from a desire to remain at
home for as long as possible during the pre- or early stages of
labour. There is a wider recognition that the home environment
carries many positive aspects for women. Over the years,
there have been many attempts to make the hospital as
home-like as possible; for example, recently in the UK, the
Healthcare Commission scored highly those trusts which pro-
vided a ‘homely’ labour ward (Healthcare Commission, 2008).
However, changing the de ´cor is no exchange for the true home
environment. For those women who choose to give birth at home,
its familiarity and support emerge strongly as features which
actively facilitate the birth, in other words, these qualities are
seen to contribute significantly to encourage women to relax and
labour (Sj¨ oblom et al., 2006). In that study, women talked of
‘incorporating the birth into their everyday lives’, and while the
study respondents gave birth in hospital, their accounts of their
cervical ripening days provide evidence that they felt that, during
their time at home, they were able to continue with normal life
during this period—and that this was seen as both appropriate
Freedom of movement, having the autonomy to decide when
to sleep or eat is part of the broader desire for control over the
birth experience (Viisainen, 2001; Green and Baston, 2003; Shetty
et al., 2005; Sj¨ oblom et al., 2006). Literally, freedom of movement
came out as important in a number of studies; for example,
Hodnett (1989) reported on hospitalised women’s dislike of being
physically confined, while in Shetty et al.’s (2005) study (using
prostaglandin cervical ripening), 58% agreed that ‘not being able
to move around’ was an important negative feature of the
induction process. This study offered women control over the
administration of IMN as well as being able to stay in their own
personal space while it took effect, and thus figuratively offered
them more control over the process as well. While the present
study sample were destined for induction as part of routine
hospital policy unless spontaneous labour occurred, they demon-
strated the desire to maintain in control of their labour in a
number of ways; for example, by choosing to take part in the
study, and by attempting to trigger labour using well-known lay
remedies. Additionally, a keenness to try to reduce the length of
labour was often reported.
The ‘anti-hospital’ views expressed by the study sample are
paralleled with sentiments from those undertaking a home birth,
although the study sample made it clear that they did not wish to
remain at home for the birth. Nevertheless, there is a striking
similarity of language between the study sample and women
choosing a home birth to describe the home (supportive, familiar)
and the hospital and its environment, with concepts of anonym-
ity, alienation and lack of support (Sj¨ oblom et al., 2006; Johnson
et al., 2007). Control was also experienced through the feeling of
safety bestowed by familiar items, such as their own bed. Finally,
the constancy of social support was seen as vital to the security of
M.R. Reid et al. / Midwifery 27 (2011) 30–35
feeling about being at home, which was contrasted with the
Swedish research confirms the significance of control and lack
of dependence on others as key concepts during childbirth.
Nystedt et al. (2006) showed that a lack of control over their
bodies and dependence upon professionals were two negative
issues for women with ‘prolonged’ labour.
One of the main issues with any development of new
technology or procedure is whether those receiving it would
repeat the experience. Data from both this substudy and the main
RCT results (Bollapragada et al., 2009) have shown that the great
majority of women were very positive about the experience.
However, the sample’s experience was both of a new treatment,
the IMN, and also the home setting. Research suggests that both
were pleasing. Bullarbo et al. (2007) similarly found that
women were positive or very positive about the treatment
(IMN administered as outpatients and then allowed home)
and the majority would recommend the procedure. In this
substudy, however, women reported being at home as the main
significant factor, while the issue was also anticipated by Osman
et al. (2006) in the ‘PRIM’ study in which women were
randomised to outpatients with IMN or prostaglandin E2. Their
sample said that they would have preferred to have been at home
during cervical ripening, with more than half of the IMN group
(54.9%) agreeing with this preference compared with only 17% of
The substudy findings are significant in that all the sample
responded positively to remaining in the home setting, although a
few had reservations such as concern over headache or minor
worries about the drug’s effects in ripening the cervix. The study
respondents felt that the opportunity to administer the drug in
the home gave them greater control over the early birth
experience, and enabled them to spend longer in a supportive
environment. This is one of the main findings of the trial and one
which researchers should explore in greater detail. Undergoing as
much of the birth process as is safe and appropriate in the home
offers women the potential for greater satisfaction with their
birthing experience in the future.
family visitswere restricted.
The authors would like to thank the women interviewed and
the staff at the Princess Royal Maternity Hospital. We are grateful
to the Data and Safety Monitoring Committee: Dr. Philip Owen,
Dr. Lena Macara and Professor Deirdre Murphy. Our thanks to Dr.
Andrew Thomson for being the independent chair of the Trial
Management Committee. We also thank Dr. Inass Osman and
Professor Ian Greer for help securing grant funding. The study was
funded by Wellbeing.
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